Thursday, September 16, 2010

Precepting Students

I've precepted many NP students during the years and usually had pretty rewarding experiences. (There was that one student that just didn't get it...I guess I can save that one and how I handled it for another post!) I like to think of precepting as a two-way street: my student is getting the hands on experience of patient care with guidance while I can further hone my precepting skills. Precepting a student is not simply telling them how to treat a condition or how to prescribe a medication. It is helping that student critically think to formulate differential diagnoses and treatment plans. Precepting can often be overlooked as part of the education and training of health professionals yet it is a critical part of acquiring the necessary skill set of patient care.

I think back to my experiences as a student and have found supportive clinicians that helped to shape me into the clinician I am today (I was precepted by a Doctor of Osteopathic Medicine, an OB/GYN, a family nurse practitioner and a emergency department physician). I wish I had more time with a nurse practitioner preceptor but one simply wasn't available to me. I believe that made it harder to find my identity as a NP since I had to constantly bring in the nursing perspective melded with the medical piece. However, that enabled me to create that identity from scratch and make it my own.

Now I am curious. As a clinician (MD, NP, PA, etc) do you precept students? What do you look for in a preceptee? Do you feel that it is your professional responsibility to help train the next generation of providers? As a student, what qualities do you look for in a preceptor? What were some examples of good or bad experiences?

I'd love to hear your feedback.

Thursday, September 2, 2010

The ER Study

"Hey, How are you doing today?"

This is supposedly the way that many nurse practitioners (and physician assistants) introduce ourselves to patients according to Gary Larkin, M.D. who recently conducted a study published in the American Journal of Bioethics entitled, "Patient willingness to be seen by physician assistants, nurse practitioners, and residents in the emergency department: Does the assumption of assent have an empirical basis?"

This study is a thinly veiled turf attack on both nurse practitioners and physician assistants. From the beginning of the article, the authors write:

"...physician substitution has often been covert in the emergency department (ED), confusing patients as to provider identity and appropriate scope of practice. This confusion may be heightened as junior doctors and nonphysician clinicians alike wear the same long white coats and Littmann stethoscopes as experienced physicians."

I retrieved the article myself to understand their methodologies and conclusions. Predictably, they found that their sample (n=507) of already waiting patients in area Emergency Departments would prefer to see a physician for their ER condition rather than NPs, PAs or medical residents. (They also sampled PAs & medical residents (n=212 & n=251 respectively) who also showed preference to an attending ER physician for moderate to complex conditions). The authors are under the assumption that all NPs and PAs are out to dupe patients into thinking we are "real doctors" without ever introducing ourselves or stating our credentials. They even go so far as to suggest that informed consent should be obtained from patients whenever a non-physician provider is caring for a patient. (Here is a post by a fellow blogger who is a PA and he points out some very well stated other methodological issues about the study.)

Do we really need a study like this? Does this add anything to the body of evidence for improving care? Perhaps we should be asking questions like, "Why are you using the emergency room for minor cold symptoms?" This study is from the same author who in 2001 surveyed medical residents with similar questions about care from NPs, PAs & medical residents and found similar results. In addition, approximately 1/3 of those residents viewed NPs & PAs as professional threats.

I clearly introduce myself literally dozens of times throughout my day and my patients still refer to me as "doctor" - even after I correct them each time. (Perhaps its my neatly pressed long white coat and fancy gray Littmann Cardiology II stethoscope?) I am addressing my patients health care needs, working with them on treatment plans/solutions and that is perhaps who they identify as a "doctor."

There are plenty of folks who need care from all members of the health team. I can't help but wonder what drives this physician-centric mentality.

And this comes out on the heels of a new study by the RAND Corporation that concludes 13.7% of all ED visits can be treated at a retail clinic. (As a reminder, most retail clinics are staffed exclusively by NPs and/or PAs). In addition, the two major retail clinic chains claim to have seen millions of patients since their inception. While quite unscientific, this fact seems to suggest that some patients actually chose to have care provided by NPs/PAs.

NPs & PAs have different education and skill sets than physicians (this is perhaps the only point that everyone can agree upon). If you as a patient are seeing an NP or PA in a health facility, you can assume that the provider in duly licensed, credentialed and/or board certified in their respective profession. These are not providers in training. They have met certain educational and training requirements and are ultimately held responsible for the care rendered. Why must it always be one or the other mentality? To put it simply, we are all similar but different. We all must coexist in order to deal with the many complexities and intricacies of the dysfunctional health care system. We spend far too much time focusing on professional shortcomings rather than strengths. Maybe if we did this, we wouldn't have millions of patients with such poorly controlled diabetes, hypertension, etc. It's easy to place blame on the patient, it's time for providers to take accountability, responsibility and start working together as a system rather than the mess we have today.